NIOSH Cedar Fire Report
CDF Cedar Fire Report
Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
FIRE PROTECTION DISTRICT
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
Cedar Fire Lessons Learned
During the day to day operations, the Novato Fire Protection District
equips each Type III engine with the following radios:
VHF High Band Mobile: One Kenwood TK-790 multi-channel, scanning
radio, with external radio speaker. The radio is programmed with
Marin and Sonoma County local government, CDF and NIFC frequency
VHF Low Band Mobile: One Motorola MaraTrac multi-channel, scanning
radio with external radio speaker. The radio is programmed with
Marin County local government frequencies.
VHF High Band Portable: One Bendix King EPH/EPI Series multichannel,
scanning radio with onboard charger and backup “clam shell”
with AA batteries. The radio is programmed with all Marin and
Sonoma County local government, CDF, USFS and NIFC frequency banks.
2 of the 15 available frequency banks are left blank for incident
- VHF Low Band Portable: One Motorola MT-1000 multi-channel, scanning
radio with onboard charger. The radio is programmed with Marin County
local government frequencies.
Day-to-day Fire District operations are dispatched and conducted
on low band frequencies.
The Novato Fire Protection District also maintains a cache of high
band and low
band portable radios for use during greater alarm incidents and mutual
At the time of the Cedar Incident the availability of spare high
band portable radios from the radio cache had been diminished due
to the fact that 2 other Novato Fire Protection District engines were
committed the mutual aid assignments in Southern California.
When Engine 6162 responded to the Cedar Incident, the crew was equipped
with two Bendix King high band portable radios.
Individual crew members responded with their personal cellular telephones.
No Fire District cellular phone was installed in Engine 6162 . The
one extra Fire District cellular phone assigned to operations had
been used by the crew responding on OES E235 two days prior to Engine
6162 responding to the Cedar Fire.
The Task Force Leader of XAL2005A directed the engines to utilize
White 2, a State of California high band channel, as their inter-crew
travel channel to San Diego.
When the Task Force arrived at the Cedar Incident Base on October
28, 2003, the crew had their Bendix King portable radios cloned with
the incident frequency load by the Communications Unit. The incident
frequency load was cloned onto one of the two blank frequency banks.
The crew of Engine 6162 received a briefing on the Communications
Plan from the Communications Unit while the high band Bendix King
radios were cloned with the incident frequencies on the afternoon
of October 28.
On October 28, the crew of Engine 6162 loaned one of their Bendix
King radios to the Task Force Leader. The radio was loaned because
the Task Force Leader did not have a high band portable. This left
the crew of four on Engine 6162 with one High Band Bendix King radio.
No other high band portable radios were available from the Communications
Unit at the time.
At the time of the burnover Engine 6162 was communicating on the
appropriate Tactical and Command Channels.
During critical periods of their operations, communications between
crew members of Engine 6162 were effectively conducted by means of
face-to-face. Radio communications were not a factor at this time.
Captain McDonald’s Bendix King portable radio was dropped on
the patio adjacent to the house and burned. It is apparent that the
radio was dropped by Captain McDonald while attempting to rescue Engineer
Rucker after making a “firefighter down” announcement.
Mobile communications equipment on Engine 6162 remained undamaged
and intact during the burn over. Captain McDonald made a mayday call
on the Command Channel using the high band Kenwood mobile radio during
their escape from 920 Orchard Lane.
Once Engine 6162 made it to a safe area, subsequent radio communications
were effective in coordinating their medical evacuation and apprising
the Incident Command Team Command Staff of what had occurred.
Post Incident Considerations
An external high band speaker would have enhanced the communication
Engine 6162 in the absence of high band portable radios for each crew
Supplying all engine crew members with portable radios capable of
transmitting and receiving on the tactical and command frequencies
assigned to the incident would enhance firefighter safety and provide
redundancy due to failure or loss. After giving their second portable
radio to the TFL the crew of Engine 6162 had one portable remaining.
This radio was with Captain McDonald and was destroyed in the burnover.
If they had not been able to make it back to the engine or if the
engine had been damaged, they would not have had the ability to request
the assistance necessary for survival.
Any change in the Communication Plan impacting tactical resources
must be communicated to all of those resources and a confirmation
received from them acknowledging the change. TF XAL2005A was aware
of a change in the plan since they had their radios updated the morning
of October 29.
The ability to manually program the portable and mobile radios may
be valuable when cloning services are not available.
Having both onboard chargers and “clam shell” backup
battery power with extra batteries is essential to reliable radio
The Communication Unit should be used to obtain or replace radios.
Loaning radios between members of a Strike Team or Task Force should
be considered as a last resort. All resources should respond to incidents
with the appropriate radio equipment.
Ideally the Communications Unit should have sufficient portable radio
supplies to meet the anticipated needs on the incident. In times of
extreme drawdown this will not always be possible. Responding resources
should not rely on solely on the ability of the Communications Unit
to provide communications equipment.
The utilization of separate radio frequencies, other than the assigned
incident tactical frequencies, for intra-crew communications, can
lead to situations where resources may be unable to transmit or receive
critical incident information. Strict adherence to the incident assigned
frequencies should be maintained by all resources.
Consideration should be given to installing cellular phones in all
If assigned tactical frequencies are overloaded with radio traffic,
this situation should be communicated through the chain of command
for the command staff to resolve.
Despite the life threatening conditions encountered by Engine 6162,
the May-Day transmissions made by Captain McDonald were clear and
concisely relayed the severity of the situation.
reading—Novato FPD Report, Lessons Learned, Suppression Equipment